Healthcare IT

Innovations for better care

Thomas M Eberle

Innovations will move to areas of consumer empowerment by providing greater access to services and information including personal health applications populated with data.

The unique aspects of the US healthcare system result in a huge underinsured or uninsured population with income too high to qualify for governmental healthcare. The need to provide even minimal care to this growing number of uninsured Americans results in some degree of cost shifting to those with insurance, further adding to the cost burden of employers.

Intel Corporation Chairman and former CEO Craig Barrett is a member of the United States Health and Human Services American Health Information Community and has taken a strong affirmative position on the role of employers in health care reform. "The current healthcare system is economically unsustainable and negatively impacting our nation's ability to compete globally", noted Barrett at the eHealth Initiative's Health Information Technology Summit. "It's time for a systemic transformation, and US employers must lead," he said.

The advent of the Internet and freely available web-based applications resulted in an opportunity for employers and vendors of wellness applications.

Barrett at the eHealth Initiative's Health Information Technology Summit went on to describe ways in which the technological approaches that companies have adopted to solve their problems could be adapted to healthcare. This will require overcoming barriers to IT adoption and acceptance of interoperability standards to foster data exchange. Employers, due to their purchasing power, should be in the forefront of driving system changes.

"Employers and their employees have the most to gain from creating a viable healthcare system", said Barrett. "Improved healthcare depends on good information. The employer's role is to get this information into the hands of their employees to make better healthcare and lifestyle choices."

Traditional wellness programmes

It is well established that direct links exist between disease and lifestyle. Tobacco, alcohol, poor diet and sedentary lifestyle have documented connection to serious diseases such as cancer, chronic obstructive pulmonary disease, diabetes mellitus, hypertension and atherosclerosis. An analysis based on literature review by Colditz in 1999 estimated the direct costs of sedentary lifestyle (defined as absence of leisure time physical activity) at US$ 2.4 billion or 2.4 per cent of US health expenditures in 1995 dollars. They estimated the cost of obesity (BMI greater than 30) independent of sedentary lifestyle at US$ 70 billion. Together, this comprised an estimated 9.4 per cent of healthcare expenditure in the US. When other potentially modifiable causes are added to the equation, it is clear that this is a reasonable target for intervention.

The advent of the Internet and freely available web-based applications resulted in an opportunity for employers and vendors of wellness applications. Not only could these applications provide all types of wellness information, but also the capability to interact with an online tool, gave the employee the opportunity to enter health data and receive a complete health risk assessment. The challenge has been getting employees to use these tools, and once they have used them, to act on the results. Various methods have been employed to increase uptake including direct incentives (cash, gift cards, etc.). Similarly, employers have used incentives to modify employees' high-risk behaviour; though monitoring compliance with smoking cessation or exercise is more problematic. Though health savings from these types of programmes can be difficult to measure and published data is sporadic, the city of Glendale, Arizona reported in the early 1990s that its nine-year-old wellness programme was saving US$ 10 for every dollar spent.

Consumer-centric health and PHRs

The logical extension to the wellness application is the concept of a Personal Health Record (PHR). Although there is as yet no uniformly accepted definition of what constitutes a PHR, it is generally agreed that it contains an electronic record of an individual's health information. In this context, we will consider the PHR as a portable, life-long record with data from a variety of sources that remains under the control of the consumer. The availability of personal data allows the application to offer health data to the consumer tailored to his / her particular needs.

One of the major issues with PHRs has been consumer adoption. Many entrants in the industry have provided applications that are totally or mainly dependent on the consumer to enter his / her own health data. The dynamic nature of health data, not to mention the arcane terminology, makes this difficult and limits acceptance. Recently, a coalition of large employers including Intel, Wal-Mart, Pitney Bowes, AT&T, sanofi aventis, Applied Materials, BP America and Cardinal Health have created a not-for-profit organisation to fund and foster the development of a personal health infrastructure called Dossia. This is being developed with the assistance of the Boston Childrens Hospital Informatics Program based on their Indivo architecture. The goal of this effort is to create a system that will allow users who opt in to have their health data auto-populated to their records from a variety of sources. These sources will initially be insurance claims databases, but it is hoped that ultimately this data will be superseded by actual clinical data derived from electronic medical record systems. Sitting atop this infrastructure will be an ecosystem of personal health applications that the consumer chooses to organise, track, and display the data to meet her particular needs, whether they be wellness, disease management, health finance, caretaker support or others.

Contentious issues

Ultimately, a system of this type if fully realised could give consumers and their care providers a common set of data on which to collaborate. The benefits include reduction in errors, elimination of duplicate services, and more efficient delivery of care utilising new paradigms of partnership. While these goals are doubtless worthwhile, there are many barriers that remain to be resolved.

Privacy and security: Both physicians and consumers are highly concerned about security and privacy of medical data. Any employer-initiated efforts will need to assure users that there is an arms-length relationship to the personal health repository and that there is no chance of this data being used to affect employment status or insurability. A myriad of state and federal laws need to be considered in dealing with special categories of data (e.g. mental health, chemical dependency) and users (e.g. adolescents).

Data availability: As of 2005, according to a survey by the National Ambulatory Medical Care Survey, only a quarter of the US physicians were fully or partially utilising an electronic medical record, and though the numbers are steadily increasing, much medical data is still inaccessible electronically. Even when EMRs are used, they often lack interoperability with other systems, making smooth data exchange a problem. For this reason, many efforts in the PHR area are utilising data from payer claims databases and pharmacy benefit managers.

Consumer acceptance: Adoption of PHRs has been consistently low. There are many factors that include lack of understanding, need to self-populate and maintain data, and lack of trust. It is documented, however, that when the concept is explained to consumers, many indicate an interest in these types of applications. According to consumer research by the Markle Foundation as part of the Connecting for Health project, adoption is likely to be highest among those with chronic conditions, younger consumers comfortable with the internet, and those who act as caretakers for others.

Provider acceptance: For PHRs to be truly meaningful to consumers, they will need to become tools for interaction and partnership with their care providers. For this reason, clinicians will need to be engaged early and actively in the discussion. Data sharing with patients needs to be seen as mutually beneficial and not a hindrance to work flow. Furthermore, physicians who are often distrustful of data, where the source is not clear, must have a level of assurance that the PHR will differentiate the data that is patient-sourced from the data that comes from within the healthcare system.

Conclusion

Employers are increasingly engaging in discussions of ways to lower healthcare costs. Traditional wellness solutions are evolving to include new applications that will give employees access to more of their personal health data and will provide tools to help them act positively on this data. Informed and engaged consumers, in partnership with their care providers, can reduce costs by improving high-risk behaviours, reducing errors and eliminating redundancy. Barriers exist, but broad consumer acceptance has the chance of driving change that will benefit not only employees and their employers but also society as a whole.

AUTHOR BIO

Thomas M Eberle has worked on a number of IT projects, with a concentration on the area of database technologies. Since late 2005 he has been working in the Digital Health Group as a clinical architect on the Personal Health Records team.